Relational continuity of oral health care in Indigenous communities: a qualitative study

This study is nested in a study funded by Canadian Institutes of Health Research entitled: “Oral Health Integrated into Primary Care: Participatory Evaluation of Implementation and Performance in Quebec Cree Communities” [25]. This participatory study used a qualitative approach to get a deeper insight into the perception⁶ and lived experiences commonly shared by the study participants in regard to relational continuity of care. We used a multiple case study design within a qualitative approach and developmental evaluation methodology [26, 27]. Developmental evaluation is useful in learning and adapting a complex intervention or program to the emerging conditions in collaboration with the key stakeholders [26]. The case study is an appropriate research design in evaluating and exploring a new or unclear phenomenon within its real-life setting [27].

Nine Cree communities of Northern Québec are geographically situated across 450,000 km², a vast area including nine villages with a population of nearly 18,000. The Cree Board of Health and Social Services of James Bay (CBHSSJB) is responsible for the administration of appropriate health and social services in these communities [28, 29]. The CBHSSJB has developed two Strategic Regional Plans 2004–2014 and 2017–2021 [29] that proposed implementing a model for the integrated delivery of health and social services in the Cree communities including the integration of oral health with primary care [29, 30]. In all communities, CBHSSJB operates Community Miyupimaatisiiun (Wellness) Centres (CMC) that are responsible for general medicine, home care, dentistry, and social services through a team of primary health care providers, along with one regional hospital primarily serving the largest community [31]. Regionally, they have developed a 29-bed Regional Hospital. In these communities, the dental clinic is integrated with the CMC or regional hospital [31]. The dental care providers offer public dental services at the clinic. Moreover, the dental hygienists along with community health representatives provide preventive dental care to the age group 0–9 years via school, daycare, and CMC [31].

Ethical approval was obtained from the Institutional Review Boards of the Université de Montréal and McGill University, and the research committee of the Cree Board of Health and Social Services of James Bay. This research is compliant with OCAP (ownership, control, access, and possession) principles for conducting research involving First Nations communities [32]. Written informed and oral consent was obtained from the study participants.

We purposefully selected four communities in terms of demographic, geographical, cultural, and health and oral health care characteristics to achieve maximum heterogeneity. Using the participative approach, the community health care providers were involved in all aspects of the study including study participant recruitment using snowball technique and maximum variation sampling [33, 34]. Participants included patients, health care providers, and administrators at CBHSSJB in the four selected communities. Data collection included face-to-face individual interviews and focus group discussions (FGD) which were conducted in a private setting at the CMCs and regional hospital. These data were collected by the teams of two researchers trained in qualitative research. There was no existing relationship between the interviewers and the participants. An interview guide with open-ended semi-structured questions was developed based on the study’s conceptual framework, the Five Foundations for Integrated Care [11], which was then tailored based on the study participant’s profile (patients, administrators, health care providers). The five foundations for integrated care include patient access, patient-centered care, management continuity of care, relational continuity of care, and informational continuity of care [11]. This study was focused on an in-depth investigation of the relational continuity of care.

Data analysis included transcription, debriefing, codification, data display, thematic analysis, and triangulation [35]. All the interviews and focus group discussions were audio-recorded and transcribed verbatim. We employed an inductive thematic analysis approach using ATLAS.ti 8 software and segmented data to analyze the relational continuity of integrated primary oral health care. Initial codes were generated followed by allocation of these codes to potential themes. Multiple potential themes were identified and grouped under overarching themes for discussion [36]. Transcription, coding, and thematic analyses were conducted by two research trainees (RS, SLL) followed by cross-examination and investigator triangulation of data by a lead researcher (EE) to enhance the quality of the findings. The thematic analysis was revised by the nominated community stakeholders and other team members. The recommendations outlined in the Consolidated Criteria for Reporting Qualitative Studies (COREQ) were utilized to guide the reporting of our findings [37].

Relational continuity progresses gradually with time and develops trust and confidence in patients towards health care providers. Participants identified the shortage of permanent dentists and their continuous transitions as a barrier and a challenge for the relational continuity of care at the different levels of the health organization. Yet some communities have enough permanent dental health care providers; participants mentioned their shortage as a challenge to relational continuity.

He’s [dentist] only here temporarily [. . . .] It’s difficult for [the dental team] to always readjust to everybody coming and going [. . .] and the population also feel the movement, […] so it’s difficult for them to trust the dental team overall. (Administrator 1, FGD)

They also mentioned that the impermanence of the dental health care providers may be the source of distrust of care, on the part of patients. Development of distrust was noteworthy in the case of providing dental services to children.

The first dentist I had, she explained to me that I need a cleaning [. . . .] I relied on that, but she’s not here anymore! And then, I’ve seen another dentist [. . .] he had to fix cavities and he didn’t proceed in my last dentist’s schedule, like I was supposed to get this cleaning. (Patient 1, interview)

But I know this, my children are [. . .] sometimes they afraid when there is new dentist . . . so, ya, there is a difference [in the approach]. I think [. . .] they don't know the children. (Patient 2)

Participants desired to have permanent dentists not only to establish individual patient–provider trusted relationship but also to achieve positive health impacts at the community level.

May I’ve got the same dentist since thirty years [. . .] . And I wouldn’t change . . . . Because he got all of my things and he follow-up on my things [. . .] . When it’s permanent staff, the population is better because she is being to be known by the nurse, by the doctor. When it’s permanent staff, the population is always better served. (Primary health care provider 1, FGD)

Although the patients’ desire was to improve relational continuity with the presence of permanent dentists, the shortage of dental workforce in the primary organization hindered this need because of the priority for receiving care rather than investing in relational continuity of care.

I told [. . .] you can just call me up my extension, you know just call me whenever there is an opening, I could just run there [. . .] cancel what I am doing and just run there. (Primary health care provider 2, interview)

Participants linked impermanence to communication gap for the incoming health providers. This communication gap affects the smooth coordination of patient’s follow-ups. In this situation, new care providers may require additional support in navigating this transition phase and in maintaining smooth communication and coordination.

The fact that people go and come, doesn’t make it easy. And there is not necessarily [. . .] a follow-up on the person that left, had that kind of things going on so when the other people will come and replace, … they should keep following up on that, so it’s just to keep the communication going but yeah , we have to have a link with them at all times. (Patient 3, interview)

Lack of effective bidirectional communication between patients and health care providers was also expressed as an element of relational continuity. The communication in local language facilitates the transmission of information and understanding among community residents. The language barrier was expressed as a major barrier of the relational continuity of care especially in case of children and elderly patients.

They don’t give us much information when you just talk to them in English. But when you communicate in Cree, it’s easier for them. (Primary health care provider 3, interview)

The communication is not there, and they understand very, very limited [. . .] their understanding is basically yes and no. (Patient 4, interview)

I think one of the things [. . .] is the communication, is the language, yes Cree is the predominant language here [. . .] and sometimes the clients come in [. . .] they have their language barrier between the dentist and whatever staff and yet maybe some of them learn in school but don’t want to speak the language [. . .] and that’s what we see, we have it in kids, we have it in the adults that don’t want to speak [. . .] that don’t have the full understanding of the English language [. . .]. (Administrator 2, interview)

The presence of local and Indigenous health care providers was identified as instrumental for a culturally competent communication and continuity of care. These local health care providers act as a link between non-Indigenous care providers and patients by translating the communication among them whenever required. They act as the gatekeeper of the continuity of care by maintaining the continuity of services in case of professional turnover.

When there is little kids and they don’t speak English or French or when elders they don’t speak French or English and [local health care provider] are here to explain, you’re gonna translate. And I think this is really a key factor. (Dental care provider 1, FGD)

They [Indigenous dental secretary or dental assistant] are the bridge between the dentist and the patient, so [. . .] they are Cree and the message goes much faster and easier, because it’s in the cultural context, it’s much easier to message to transmit easier, like if I tell a patient that you need to brush more, the message sometimes doesn’t go through as quick, but if it’s by them, it’s faster. (Dental care provider 2, interview)

Participants valued interprofessional teamwork and coordination for health care services in the organization. They mentioned that dental health care providers, primary health care providers, and community health representatives were collaboratively working on the patient’s care to improve relational continuity of care.

It [trust] comes with time, it depends on how you’re gonna interact with the assistant, with the secretary, with the hygienist, with the patient, you know with everyone. (Dental care provider 1, FGD)

Well I do the teachings even if the pamphlets are not there, from what I remember, I do teach the parents to really work on the health of the child. (Primary health care provider 3, interview)

We have a very strong team, team works as an interdisciplinary team and they collaborate very well with each other and within the different services that they provide. (Primary health care provider 4, interview)

The organization is taking initiatives to maintain the relational continuity of care and fill the communication gaps. The organization has the provision of appointing replacement dentists in case of absence of working dentists as a step to fill the gaps in care continuity.

Sometimes we have “permanent replacing dentist” [. . .]. That’s like a replacing dentist only doing replacement. We are calling them permanent replacing dentists as they are coming often in the same community, but they are replacing the permanent dentists [. . .]. So [. . .] they can build, and they have built the trust between patients. (Dental care provider 1, FGD)

Other initiatives included organizing meetings for new care providers and developing a guideline for replacements and new dentists that helps them to understand their role and work culture at the clinic.

It is a job description, it is the same document we use as a guideline for dentist when they arrive, and they are new. And it gets a little bit better, but then with time, we lose them, and we have someone new and it’s hard to keep the same balance. But at least with that new tool [that is] provided to all the new dentists that come in the territory and it’s basically a guideline without putting any name on the forms: what goes well, what does not, what improves, what needs to be worked on more. (Administrator 1, FGD)

When we have new workers, we have a meeting with them [. . .] we talk with them about this is the way you fill the file, etc. (Dental care provider 3, interview)